MO HealthNet Hysterectomy Information Form

1. MO HealthNet Internet Provider Training Program Presented by the Provider Education Unit MO HealthNet Division MO HealthNet Division

2. Proper Completion of a Paper Acknowledgement of Receipt of Hysterectomy Information Form Presented by the Provider Education Unit MO HealthNet Division MO HealthNet Division

3. MO HealthNet Division

4. Acknowledgement of Receipt ofHysterectomy Information Form Name of Participant MO HealthNet ID Number MO HealthNet Division

5. Acknowledgement of Receipt ofHysterectomy Information Form Name of Representative Source of Hysterectomy Information MO HealthNet Division

6. Acknowledgement of Receipt ofHysterectomy Information Form Medical Reason for Hysterectomy Signature and Title of Person Securing the Authorization Date(Month/Day/Year) MO HealthNet Division

7. Acknowledgement of Receipt ofHysterectomy Information Form Physician/Clinic Name MO HealthNet Provider Identifier Provider Taxonomy Code MO HealthNet Division

8. Acknowledgement of Receipt ofHysterectomy Information Form Date (Month/Day/Year) Signature of Participant MO HealthNet Division

9. Acknowledgement of Receipt ofHysterectomy Information Form Reason Participant Incapable of Signing MO HealthNet Division

10. Acknowledgement of Receipt ofHysterectomy Information Form Signature of Representative Relationship to Participant Date (Month/Day/Year) MO HealthNet Division

11. System Form Processing The claim for the hysterectomy will suspend for 45 days to look for the completed Acknowledgement of Receipt of Hysterectomy Information form. Each day, the system will look for the approved form. At the end of the 45 day period, if no form is found, the claim will deny and the provider will have to re-file the claim and the form. MO HealthNet Division

12. You may either mail the completed Acknowledgement of Receipt of Hysterectomy Information Form to Infocrossing Healthcare Services, Inc., P.O. Box 5900,Jefferson City, MO 65102 or you may enter the information from this form via the Internet at www.emomed.com. MO HealthNet Division

13. Acknowledgement of Receipt of Hysterectomy Information Requirements The Acknowledgement of Receipt of Hysterectomy Information form must be completed when a hysterectomy is to be performed which is not precluded from MO HealthNet reimbursement under Federal Regulatory provisions at 42 CFR 441.255(a) and which is not exempted from the requirement for this documentation under provisions at 42 CFR 411.255 (b) and (e). MO HealthNet Division

14. The requirement for the Acknowledgement of Receipt of Hysterectomy Information applies to an individual of any age. • The form must be signed by the participant or her representative, if any, prior to surgery. • Hysterectomies for family planning purposes are not payable through MO HealthNet or any other federally funded program, nor from general relief or blind pension programs. MO HealthNet Division

15. Exceptions to the requirement of the Acknowledgement of Receipt of Hysterectomy Information • The individual was already sterile before the hysterectomy. The physician who performs the hysterectomy must certify in writing that the individual was already sterile at the time of the hysterectomy and state the cause of the sterility. This must be documented by an operative report or admit and discharge summary attached to the claim for payment; MO HealthNet Division

16. Exceptions to Hysterectomy Form (continued) • The individual requires a hysterectomy because of a life-threatening emergency situation in which the physician determined that prior acknowledgement is not possible. The physician must certify in writing to this effect and include a description of the nature of the emergency; or MO HealthNet Division

17. Exceptions to Hysterectomy Form (continued) • The participant was not MO HealthNet eligible at the time the hysterectomy was performed but eligibility was made retroactive to this time. If you are unable to obtain an eligibility approval letter from the participant, the claim may be submitted along with a completed Certificate of Medical Necessity form indicating the participant was not eligible at the time of service but has become eligible retroactively to that date. The physician who performed the hysterectomy must certify in writing to one of the following situations: MO HealthNet Division

18. Exceptions to Hysterectomy Form (continued) • The individual was informed prior to the operation that the hysterectomy will make her permanently incapable of reproducing, and the procedure is not being performed solely for family planning purposes; • The individual was already sterile before the hysterectomy; or, • The hysterectomy was performed under a life-threatening emergency situation in which the physician determined prior acknowledgement was not possible. A description of the nature of the emergency must be included. MO HealthNet Division

19. Obtaining a Copy of the Paper Form To obtain a copy of the form, go to the MHD public Web site, www.dss.mo.gov/mhd/providers/index.htm. In the left hand column, click on “MO HealthNet forms”. When the index of forms opens, click on “Acknowledgement of Hysterectomy”. You then can print the form once it opens up on your computer screen. MO HealthNet Division

20. Should you have further questions on how the form should be completed, please feel free to contact Roger Weis or Carol Lindemann in the Provider Education Unit at 573-751-6683. MO HealthNet Division